CVS/caremark Mail Service Pharmacy Program

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1 CVS/caremark Mail Service Pharmacy Program User Guide For Molina Dual Options Cal MediConnect Plan Medicare-Medicaid Plan Getting started is easy! If you need your prescription filled right away, ask your doctor to write two prescriptions for your long-term drugs: The first, for a short-term supply (e.g., 30 days) to be filled right away at a network retail drugstore. The second, for the max days supply allowed (up to a 90-day supply) with as many as three refills (if appropriate) to be mailed to CVS/caremark. Ask your doctor about getting a prescription for 90-days. Whether you use the CVS/caremark Mail Service Pharmacy Program or purchase your maintenance drugs at a network retail drugstore talk to your doctor today about getting a prescription for 90 days to save you money! Mail Service Order Options. If you take one or more maintenance drugs, you may save time and money with mail service and have them shipped to your home. This means fewer trips to the drugstore and the gas pump. Choose from 4 ways to order. Option 1 Mail Complete and mail the CVS/caremark Mail Service Order Form. Mail the form and payment to the address printed on the form. For new orders, don t forget to include your prescription. You can pay online from: your checking account, using Bill Me Later, or a credit card. Or you can mail a check or money order. If you mail in a payment, do not send cash. Option 2 Online Go to and sign in or register by clicking on Start a New Prescription and then click on FastStart. Option 3 Phone Call the FastStart toll-free number at (888) , Monday Friday, 9 a.m. - 9 p.m. CT. TTY users call (800) Provide your Member number (found on your Plan ID card), your prescription name(s), your doctor s name and phone number, and your mailing address. There s even a tollfree line to order refills 24/7. H8677_16_15158_142_CAMMPMailUserGuide Approved 10/26/ MMP1115

2 Option 4 Doctor Give your doctor s office the toll-free FastStart doctor number, (888) , TTY (800) , and ask your doctor to call, fax, or eprescribe your prescription. To speed up the process, your doctor will need your Member number (found on your Plan ID card), your date of birth, and your mailing address. That s it! Once CVS/caremark receives your order and payment (if required) it should take about 10 days for you to receive your order. Find out how easy it is to have prescriptions shipped to your home. There s even a toll-free line to order refills 24/7. If your order does not arrive in about 10 days please call CVS/caremark at (888) , TTY (800) , Monday Friday, 9 a.m. - 9 p.m. CT. Refill Prompts. When using the CVS/caremark Mail Service Pharmacy Program the insert you receive with your prescription(s) will show the date that you can request a refill and the number of refills you have remaining. If you request a refill too soon CVS/caremark will notify you when it s time. Need Help or Have Questions? If you need help with any formulary-related issue or simply have questions about your drug benefit, please call our Pharmacy Call Center toll-free at (855) , TTY 711, Monday Friday, 8 a.m. to 8 p.m., local time. Molina Dual Options Cal MediConnect Plan Medicare-Medicaid Plan is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees.

3 You can get this information for free in other formats, such as large print, braille, or audio. Call (855) , TTY/TDD: 711, Monday Friday, 8 a.m. to 8 p.m., local time. The call is free. You can get this information for free in other languages. Call (855) The call is free. Usted puede recibir esta información en otros idiomas gratuitamente. Llame al (855) Esta es una llamada gratuita. Makukuha mo ang impormasyong ito nang libre sa iba pang mga wika. Tumawag sa (855) Libre lang ang tawag. Bạn có thể nhận thông tin này miễn phí bằng các ngôn ngữ khác. Hãy gọi đến số (855) Cuộc gọi miễn phí. يیمكنك االحصولل على هھھھذهه االمعلوماتت مجان ا بلغاتت ا أخرىى. ااتصل على ررقم (855). هھھھذهه االمكالمة مجانيیة. 您 可 以 獲 得 本 資 訊 的 其 他 語 言 版 本 請 撥 打 免 費 電 話 (855) 索 取 Вы можете получить эту информацию на других языках совершенно бесплатно. Для этого позвоните по номеру (855) Звонок является бесплатным. 이 정보는 다른 언어로 무료로 받아보실 수 있습니다. 무료 전화 (855) 번으로 연락해 주십시오. شما می تواانيید اايین ااططلاعاتت رراا بهھ ططورر رراايیگانن بهھ ززبانن هھھھایی دديیگر نيیز ددرريیافت کنيید. با شماررهه (855) تماسس بگيیريید. هھھھزيینهھ اایی براایی اايین تماسس ددرر نظر گرفتهھ نمی شودد. អនកអចទទ លបនព ត មន ន ដយឥតគ ត ថលជភស ផសង ទ ត ហ ទ លខ (855) ករ ហទ រស ពទគ ឥតគ ត ថល Այ ս տեղեկու թյ ու նը կարող եք ան վ ճ ար ս տան ալ այ լ լ եզու ներով: Զ ան գ ահ ար ե ք (855) : Զ ան գ ն ան վ ճ ար է : Limitations and restrictions may apply. For more information, call Molina Dual Options Cal MediConnect Plan Medicare-Medicaid Plan Member Services or read the Molina Dual Options Member Handbook. Benefits and/or copayments may change on January 1 of each year. The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. H8677_16_15158_142_CAMMPMailUserGuide Approved 10/26/2015

4 Mail Service Order Form Mail this form to: Member ID # (if not shown or if different from above) ppqssqrrsprrssqrprrrrssrsqqsqqqpppsrssppqsqpspqrrrpqrrsprrpqsrppq CVS/caremark PO BOX PALATINE, IL Prescription Plan Sponsor or Company Name Instructions: Please use blue or black ink and print in capital letters. Fill in both sides of this form. New Prescriptions - Mail your new prescriptions with this form. Number of New prescriptions: Refills - Order by Web, phone, or write in Rx number(s) below. Number of Refill prescriptions: TO RECEIVE YOUR ORDER SOONER request refills or new prescriptions online at or call the toll-free number on your member ID card. A Shipping Address. To ship to an address different from the one printed above, enter the changes here. Last Name First Name MI Suffix (JR, SR) Street Address Apt./Suite # City State ZIP Code Use shipping address for this order only. Daytime Phone #: Evening Phone #: B Refills. To order mail service refills, enter your prescription number(s) here. 1) 2) 3) 4) 5) 6) 7) 8) CVS/caremark wants to provide you with high quality medicines at the best possible price. In order to do this, we will substitute equivalent generic medicines for brand name medicines whenever possible. If you do not want us to substitute generics, please provide specific instructions, including drug names, in the Special Instructions section of this form. We may package all of these prescriptions together unless you tell us not to. All claims for prescriptions submitted to CVS/caremark Mail Service Pharmacy using this form will be submitted to your prescription benefit plan for payment. If you do not want them submitted to your plan, do not use this form. You may call Customer Care to make alternate arrangements for submission of your order and payment CVS/caremark. All rights reserved. P13-N

5 C Tell us about the people ordering prescriptions. If there are more than two people, please complete another form. First person with a refill or new prescription. Gender: M F Spanish forms and labels Suffix (JR,SR) Date of Birth: MM-DD-YYYY Date new prescription written: Last Name First Name MI Address: Doctor s Last Name Doctor s First Name Doctor s Phone # Tell us about new health information for 1st person if never provided or if changed. Allergies: None Aspirin Cephalosporin Codeine Erythromycin Peanuts Penicillin Sulfa Medical Conditions: Arthritis Asthma Diabetes Acid Reflux Glaucoma Heart Problem High Blood Pressure High Cholesterol Migraine Osteoporosis Prostate Issues Thyroid Second person with a refill or new prescription. Last Name First Name MI Address: Gender: M F Date of Birth: MM-DD-YYYY Date new prescription written: Spanish forms and labels Suffix (JR,SR) D E Doctor s Last Name Doctor s First Name Doctor s Phone # Tell us about new health information for 2nd person if never provided or if changed. Allergies: None Aspirin Cephalosporin Codeine Erythromycin Peanuts Penicillin Sulfa Medical Conditions: Arthritis Asthma Diabetes Acid Reflux Glaucoma Heart Problem High Blood Pressure High Cholesterol Migraine Osteoporosis Prostate Issues Thyroid Special Instructions: How would you like to pay for this order? (If your copay is $0, you do not need to provide payment information.) Electronic Check. Pay from your bank account. (You must first register online or call Customer Care.) Use my PayPal Credit account. Works like a credit card. (You must first register online.) Credit or Debit Card. (VISA, MasterCard, Discover, or American Express ) Use your card on file. Use a new card or update your card s expiration date. Exp.Date MMYY Check or Money Order. Amount: $. Make check or money order out to CVS/caremark. Write your prescription benefit ID number on your check or money order. If your check is returned, we will charge you up to $40. Payment for Balance Due and Future Orders: If you choose Electronic Check, PayPal Credit, or a Credit Card or Debit Card, we will also use it to pay for any balance that you owe and for future orders. Fill in this oval if you DO NOT want us to use this payment method for future orders. MOF WEB 0715 MTP Credit Card Holder Signature/Date Regular delivery is free and will take up to 10 days from the day you send this form. If you want faster delivery, choose: 2nd Business Day ($17) Business days are only Next Business Day ($23) Monday-Friday Faster delivery charges may change. Faster delivery is for shipping time only, not processing. Faster delivery can only be sent to a street address, not a PO Box.

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